ASSESSING AND MONITORING LONG-TERM OPIOID USE FOR PEOPLE WITH CHRONIC AND DISABLING ARTHRITIS PAIN - ADDICTION HEALTH SERVICES RESEARCH ...
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ADDICTION HEALTH SERVICES RESEARCH CONFERENCE| OCTOBER 17, 2019
ASSESSING AND
MONITORING LONG-TERM
OPIOID USE FOR PEOPLE
WITH CHRONIC AND
DISABLING ARTHRITIS PAIN
Kathryn Paez, PhD, RN, Managing Director | Mary Lavell, MPH, ResearcherThis presentation was developed under a grant from the
National Institute on Disability, Independent Living, and
Rehabilitation Research (NIDILRR).
NIDILRR is a Center within the Administration for Community
Living, Department of Health and Human Services.
The contents of this brief do not necessarily represent the
policy of NIDILRR, ACL, and HHS, and you should not assume
endorsement by the Federal Government.
Grant number 90DPGE0006
2Arthritis, a prevalent condition, can lead to
disability and severe pain
Arthritis Prevalence1 Severe Pain and Arthritis
1 in 3 adults aged 45 2 of 4 people with OA
to 64 live with arthritis and RA report activity
limitations2,3
Nearly 1 in 3 adults with
2 in 4 adults over 65 arthritis report severe
live with arthritis pain4
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 3People With Arthritis Have High Rates
of Opioid Use
People filling 1 or more opioid prescriptions, • 1 in 3 people with
20137 rheumatoid arthritis
take opioids regularly8
• 15% to 48% of people
Arthritis with osteoarthritis take
diagnosis opioids regularly9,10
47% 53%
• 66% of people with
spinal stenosis took
opioids continuously
No arthritis 1 year after surgery11
diagnosis
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 4Prevalence of misuse and addiction among people with chronic pain6 Misuse: Use of the drug contrary to the prescriber’s directions • Opioid misuse rate: 21% to 29% (95% CI: 13% to 38%) Addiction: Continued opioid use despite impaired control, compulsive use, craving or demonstrated potential harm • Addiction rate: 8% to 12% (95% CI: 3% to 17%) AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 5
Research study goal and approach
Goal: Support the accurate assessment of OUD in people with
disabilities taking chronic opioids while using the best evidence to
minimize over- and under-diagnosis of OUD
Research Activities
• Literature review Understand providers and
• Interviews with 56 providers, people PWD experiences related to
with disabilities and counselors opioids, identification of
• Develop OUD screening OUD and transition into
instrument treatment
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 6Qualitative Methods
• Recruitment sources: Advisory group referrals, recruitment firm, and an
online health media company
• Approach: Phone Interviews
• Analysis:
– Created preliminary codes based on interview aims and set of
questions we asked the participants
– Met regularly, discussed coding, and added new codes throughout the
process
– Mapped codes to the task aims and decided on the 13 topics for
memos
– Collectively reviewed and revised memos
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 7People with disabilities due to arthritis (PWD), n=24
Currently Treated for Total
Characteristics Taking OUD
Opioids Focus of interview
Impairment- Difficulty with
Mobility AND use of fingers AND ability
7 7 14 • Experiences
to lift, carry, or move everyday objects
1-2 impairments noted above 5 5 10 managing chronic
Chronic Condition 1
Osteoarthritis 8 9 17 arthritis pain with
Rheumatoid arthritis 10 5 15
Spinal stenosis or severe osteoporosis 5 6 11 opioids, receiving
Other 2 4 6
Gender medical care, and,
Male 4 3 7
Female 8 9 17
for half the sample,
Age, years
30-49 2 2 4
receiving treatment
50-69
Over 70
7
3
8
0
15
3
for an OUD
Unknown 2
Years on Opioids
3 month -5 years 5 -- 5
5-10 years 3 -- 3 1 Some PWD had more than 1
More than 10 years 4 -- 4
condition
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 8Providers, n = 24
Characteristics Number
Focus of interview
Provider Type
Physician 19
• Experiences
Nurse practitioner or physician assistant 5
Specialty
prescribing opioids,
Primary care providers 5 managing opioids
Rheumatologists 5
and monitoring
Physiatrists 1
Pain medicine specialists 13 patients with a
Location disability due to
Northeast and MidAtlantic 6
arthritis
South 7
Midwest 7
West 3
Unknown 1
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 9PWDs had a long history of chronic pain and
opioid use
• Many experienced chronic pain for many years and took opioids for 1 to
10 years.
• Most had exhausted other methods of controlling pain prior to use
of opioids.
• Many experienced recent changes in their opioid management.
– Difficulties accessing opioids due to insurance, state requirements,
and providers unwilling to prescribe opioids
– Had taken Vicodin or Percocet but were switched to Tramadol or
Norco, which was not always as effective
– Reduction in opioid dosage
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 10Providers follow the CDC’s chronic pain
guidelines
Opioid Prescribing Opioid Monitoring
– Assess adherence to opioid use
• Stepped treatment approach
contracts
• Detailed assessment – Regular visits and drug screens
• Consider length of relationship – Opioid misuse screening tools
and trust level and state drug monitoring
databases
• Avoid prescribing to younger – Pill counts
patients, or to those with history
– Review of safe storage
of substance use disorder
– Discussions with patients and
families/caregivers
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 11Providers and PWDs recall opioid risk and benefit
discussion differently
• People with disabilities • Providers
– Ranged from no discussion – Detailed conversation about
opioid risks—respiratory
at all to discussing opioid
depression, drug
side effects and the warning contraindications, side effects,
signs of OUD and the risks of OUD and
overdose
– Benefits of the medication and
why it was the best choice at
the time
– Instructions on safe use and
storage
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 12Providers rely on pain specialists
• Primary care providers and rheumatologists make pain program referrals
for a variety of reasons.
– Uncomfortable prescribing opioids and unsure how to manage
uncontrolled chronic pain
– Person has reached an opioid dose threshold
– Suspect opioid misuse
Rheumatologist
“I’m not writing for morphine. I used to use it sometimes…. I’ve quit because of all the
concerns about opioids.”
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 13Providers’ responses to concerns about opioid
misuse and OUD
• More confrontational approach • Less confrontational approach
– Describe (minor or major) – Deeper assessment that
behaviors not in compliance includes discussing observed
with opioid agreement behaviors, concerns and pain
– Either discharge the person control with person
without offering alternatives – Discuss for OUD treatment
or “warn” them to change their options, including
behaviors or will cease buprenorphine or suboxone, if
prescribing of opioids needed
Rheumatologist
“After a second offense, it would mean a permanent discharge from the practice and
discharge from any further opioid prescriptions.”
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 14PWD eventually sought OUD treatment and some self-identified an opioid use problem • Information from family and friends often led people to seek out treatment • Fear about where use was leading was a motivating factor Persons Treated for OUD “ “My friend had been on suboxone because she had pain and went to the same doctor. I didn’t know her. She was a neighbor. She went on suboxone and I noticed she was working and looking a lot better, and not being dependent or counting on pills. I got thinking about it and I reached out, because I really didn’t know that there was help available.” I was afraid I was going to start using heroin because of the pain. You know, using too many sometimes…and the addiction…it became really addictive, so that was when I reached out and got treatment.” AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 15
Treatment for OUD and recovery • Providers did not play a significant role in coordinating OUD treatment and follow-up care. • Barriers to access to OUD treatment – Prescribing provider does not have a buprenorphine waiver – Fear of uncontrolled pain – Lack of knowledge about options and available resources – Lack of fit with treatment program – Lack of insurance coverage and cost AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 16
Ways providers can help people access treatment • Striking the “right” tone when discussing behaviors indicative of a use disorder • Ensure person is referred into an appropriate treatment program and has pain managed while in recovery • “Warm handoff” when referring to treatment • Involve the person’s support system Persons Treated for OUD “Do not to leave your patients hanging when they do become addicted or dependent. They need the additional support and those conversations with you to make sure they get the support and the follow-up care they need.” AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 17
Project web page
https://www.air.org/project/improving-assessment-opioid-use-disorder-people-disabilities-related-chronic-musculoskeletal
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 18Notes
1. Smith SM, Dart RC, Katz NP, Paillard F, Adams EH, Comer SD, et al. Classification of misuse, abuse and related events in clinical trials:
Barbour KE, Helmick CG, Boring M, Brady TJ. Vital Signs: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity
limitation—United States, 2013–2015. MMWR Morb Mortal Wkly Rep. 2017;66:246-53. doi:
http://dx.doi.org/10.15585/mmwr.mm6609e1
2. Barbour KE, Moss S, Croft JB, Helmick CG, Theis KA, Brady TJ, et al. Geographic variations in arthritis prevalence, health-related
characteristics, and management—United States, 2015. MMWR Morb Mortal Wkly Rep Surveill Summ. 2018;67(No. SS-4):1-28. doi:
http://dx.doi.org/10.15585/mmwr.ss6704a1
3. Barbour KE, Boring M, Helmick CG, Murphy LB, Qin J. Prevalence of severe joint pain among adults with doctor-diagnosed
arthritis—United States, 2002–2014. MMWR Morb Mortal Wkly Rep. 2016;65:1052-6.
http://dx.doi.org/10.15585/mmwr.mm6539a2
4. Barbour KE, Helmick CG, Boring M, Brady TJ. Vital signs: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity
limitation—United States, 2013–2015. MMWR Morb Mortal Wkly Rep. 2017;66:246-53. doi:
http://dx.doi.org/10.15585/mmwr.mm6609e1
5. Hootman JE, Cisternas M, Murphy L, Losby J. Prevalence and trends in prescribed opioid use in among U.S. adults with arthritis,
2008–2013, Medical Expenditure Panel Survey [abstract]. 2016 ACR/ARHP Annual Meeting; 2016 Nov 11-16; Washington, DC: 2016.
Available from: https://acrabstracts.org/abstract/prevalence-and-trends-in-prescribed-opioid-use-among-us-adults-with-arthritis-
2008-2013-medical-expenditure-panel-survey/
6. Smith SM, Dart RC, Katz NP, Paillard F, Adams EH, Comer SD, et al. Classification of misuse, abuse and related events in clinical trials:
ACTTION systematic review and recommendations. Pain. 2013;154(11):2287-6.
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 19Notes
7. Hootman JE, Cisternas M, Murphy L, Losby J. Prevalence and trends in prescribed opioid use in among U.S. adults with arthritis,
2008–2013, Medical Expenditure Panel Survey [abstract]. 2016 ACR/ARHP Annual Meeting; 2016 Nov 11-16; Washington, DC: 2016.
Available from: https://acrabstracts.org/abstract/prevalence-and-trends-in-prescribed-opioid-use-among-us-adults-with-arthritis-
2008-2013-medical-expenditure-panel-survey/
8. Landsman-Blumberg PB, Katz N, Gajria K, D’Souza AO, Chaudhari SL, Yeung PP, et al. Health care resource use and cost differences
by opioid therapy type among chronic noncancer pain patients. J Pain Res. 2017;10:1713-22. doi:
https://doi.org/10.2147/JPR.S130913
9. Power JD, Perruccio AV, Gandhi R, Veillette C, Davey JR, Lewis SJ, et al. Factors associated with opioid use in end-stage knee, hip and
spine osteoarthritis [abstract]. 2017 ACR/ARHP Annual Meeting; 2017 Nov 3-8; San Diego, CA: 2017. Available from:
https://acrabstracts.org/abstract/factors-associated-with-opioid-use-in-end-stage-knee-hip-and-spine-osteoarthritis/
10. Wright EA, Katz JN, Abrams S, Solomon DH, Losina E. Trends in prescription of opioids from 2003 to 2009 in persons with knee
osteoarthritis. Arthritis Care Res. 2014;66(10):1489-95. doi: https://doi.org/10.1002/acr.22360
11. Adogwa O, Davison MA, Vuong V, Desai SA, Lilly DT, Moreno J, et al. Gender differences in opioid use in patients with symptomatic
lumbar stenosis or spondylolisthesis undergoing lumbar decompression and fusion. Spine. 2018. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/30601354
AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG 20C O N TA C T I N F O R M AT I O N
KATHY PAEZ , PRINCIPAL INVESTIGATOR
KPAEZ@AIR.ORG
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